Tuberculosis (TB) in Prisons and Immigration Removal Centres

Tuberculosis (TB) in Prisons and Immigration Removal Centres: An Evidence-Based Partnership Approach to Tackling Tuberculosis in Prisons and Immigration Removal Centres in London

Abstract

Background

The World Health Organization (WHO) has identified tuberculosis (TB) as a critical global health challenge, reporting 8.6 million active cases and 1.3 million deaths annually. The incidence of TB in the UK remains high compared to most other Western European countries, with 8,751 cases reported in 2012, an incidence of 13.9 per 100,000 population. This persistent burden underscores the urgent need for targeted interventions. London accounts for the highest proportion of cases in the UK (39%) and the highest rate of disease (41.8 cases per 100,000). Left untreated, one person with pulmonary TB may infect around 10–15 people every year. People in prison and Immigration Removal Centres (IRCs) represent a population who are at particular risk. National estimates for TB prevalence in the prison population are 208 per 100,000, and amongst London’s approximately 10,000 prison population, we would expect 20 cases, but we are seeing more than double. This discrepancy highlights the need for enhanced screening and management strategies. The cost of treating ‘normal’ TB is around £5,000 and is much greater for more socially complex cases (estimated at £50,000–£70,000). There is considerable variation in the delivery of some aspects of TB services. A co-ordinated national TB strategy is required to support locally designed and implemented services and monitor achievements against national standards. This paper presents findings from a partnership between NHS England, Public Health England (PHE), and the National Offender Management Service (NOMS) to tackle TB across its prison population in the overall approach to the TB strategy in London. Effective collaboration among these stakeholders is essential to address the unique challenges in these settings.

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Aims/Objectives

The primary goal is to assess whether national NICE guidance for TB management in prisons and immigration removal centres is being adhered to effectively. This evaluation aims to ensure that high-risk populations receive standardized care.

Methods

The target population included all 9 prisons and 3 IRCs for which NHS England (London region) are responsible. Methods used: 1) An organisational clinical audit during January 2014 using the NICE baseline assessment tool; 2) Stakeholder engagement through a steering group and a wider reference group. These methods ensured a comprehensive review of current practices and facilitated collaborative input.

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Results

Effective stakeholder engagement contributed to a 100% completion rate. All establishments had referral pathways in place and a named contact within the local Multidisciplinary TB team and the local Public Health England health protection team. This infrastructure supports timely interventions. However, 2/12 establishments did not screen for TB within 48 hours of arrival. Additionally, 3/12 did not have a local TB policy, and 2/12 lacked a named TB lead. None of the Department of Health (DH) funded X-ray machines were being used in line with NICE recommendations. Latent TB was not being diagnosed or managed. These gaps indicate areas for immediate improvement in protocol adherence.

Conclusions

Active and systematic case finding is needed within prison and IRC settings, alongside more rigorous and standardized contingency and follow-up care plans after release (or transfer). Enhanced training for staff could improve compliance with national guidelines.

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Introduction

The World Health Organization (WHO) has declared tuberculosis (TB) a pressing global emergency, with 8.6 million people affected and 1.3 million deaths annually (World Health Organisation, 2013). This significant burden necessitates robust public health responses. The six-point Stop TB Strategy (World Health Organisation, Europe, 2013b) explicitly addresses the key challenges facing TB with the goal to dramatically reduce the global burden of TB by 2015 by ensuring all TB patients benefit from universal access to high-quality diagnosis and patient-centered treatment. However, there have been challenges in developing and implementing program-wide interventions in both high-income (Migliori, Sotgiu, Blasi, et al., 2011) and middle- and low-income countries (Cobelens, van Kampen, Ochodo, et al., 2012). These challenges highlight the complexity of TB control across diverse socioeconomic contexts. England and Wales have responded to the need to tackle TB, where the NHS and the Department of Health have developed a national Action Plan for ‘Stopping Tuberculosis in England’ (Department of Health, 2004). NICE has also developed a set of national guidance for the identification and management of TB across various settings (NICE public health guidance, 2011), which emphasizes the need for a multi-agency approach. There has been little evidence evaluating the implementation of these guidelines. Addressing this gap is crucial for refining TB control strategies.

What is TB?

TB is caused by Mycobacterium tuberculosis, which spreads in airborne droplets when people with the disease cough or sneeze. Most people infected with M. tuberculosis never become ill as their immune system contains the infection. This latent state can persist without symptoms for years. However, the bacteria remain dormant (latent) within the body, and a latent TB infection can cause active disease many years after the initial infection if immunity declines. The symptoms of TB include a persistent cough, weight loss, and night sweats. Early recognition of these symptoms is vital for timely diagnosis.

The BCG vaccine (Bacillus Calmette-Guérin vaccine) protects against TB, and it was once thought possible to eradicate TB through a vaccination program. The BCG vaccine is made from a weakened form of a bacterium closely related to human TB. Because the bacterium is weak, the vaccine does not cause any disease but still triggers the immune system to protect against the disease, providing good immunity to those who receive it. This vaccine has significantly reduced severe TB outcomes in vulnerable populations. In the past, the BCG vaccination program was delivered to all teenagers in the UK, but as TB is a difficult disease to catch because it requires prolonged exposure to an infected person, it was changed so that now only people in at-risk groups are given the vaccination. The vaccine is 70-80% effective against the most severe forms of TB, such as TB meningitis in children, but it is less effective in preventing respiratory disease, which is the more common form in adults (Trunz, Fine & Dye, 2006). Even with the high coverage now achieved, BCG is unlikely to have any substantial effect on transmission. Ongoing research is needed to develop more effective vaccines.

Risk factors that seem to be of importance at the population level include poor living and working conditions associated with a high risk of TB transmission, and factors that impair the host’s defense against TB infection and disease, such as HIV infection, malnutrition, smoking, diabetes, alcohol abuse, and indoor air pollution. Preventive interventions may target these factors directly or via their underlying social determinants. Addressing these social determinants can significantly reduce TB incidence. The identification of risk groups also helps to target strategies for early detection of people in need of TB treatment (Lönnroth, Jaramillo, Williams, et al., 2009). Tailored interventions for these groups enhance the effectiveness of TB control programs.

How Common is TB in the UK?

Eradicating TB both globally and in the UK has proven to be a formidable challenge. Vaccination programs and improvements in housing, nutrition, and access to treatment have been largely responsible for a global decrease in TB. These advancements have saved countless lives. However, TB remains prevalent in less developed countries where poor conditions persist. Several strains of TB bacteria have developed resistance to one or more anti-TB medications, making them much harder to treat. The global epidemic of HIV that began in the 1980s has also led to a corresponding epidemic of TB cases. This is because HIV weakens a person’s immune system, making them more likely to develop a TB infection. The rapid growth of international travel has allowed people to travel widely, and this has facilitated the spread of the disease. Enhanced global surveillance is critical to track and control TB spread.

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Although the rates of TB have stabilized in the UK over the past seven years, following the increase in incidence from 1990 to 2005, the incidence of TB in the UK remains high compared to most other Western European countries (Hayward, Darton, Van-Tam, et al., 2003). There were 8,751 cases reported in 2012, an incidence of 13.9 per 100,000 population (Health Protection Agency, 2013b). This high incidence underscores the need for sustained public health efforts. The majority of TB cases (73%) occurred among people born in high-incidence countries and are generally concentrated in large urban areas with a high proportion of people born outside the UK, where the rate of TB among the non-UK-born population is almost 20 times the rate in the UK-born (Health Protection Agency, 2013b). Targeted screening in these communities can help reduce disparities.

London accounts for the highest proportion of cases in the UK (39%) and the highest rate of disease (41.8 cases per 100,000), followed by the West Midlands (12%; 19.3 cases per 100,000). Left untreated, one person with pulmonary TB may infect around 10–15 people every year (Department of Health, 2004). This high transmission rate emphasizes the importance of early detection and treatment.

TB in Prisons

Identifying settings where the risk of TB transmission is particularly high is a priority for public health efforts. Groups at risk not only include people born in high-prevalence areas (e.g., sub-Saharan Africa, South East Asia, Eastern Europe) but also people with reduced immunity (e.g., HIV, diabetes, renal failure), those with alcohol or drug problems, and people who are homeless or living in overcrowded conditions (Story, Murad, Roberts, et al., 2007). These risk factors are overrepresented in prison populations with high levels of social and health needs. A systematic review on the incidence of TB in prisons globally (largely in the USA) showed that TB was about 26 times higher than in the general population (Baussano, Williams, Nunn, et al., 2010). In the London prison population, the incidence of TB has been estimated at about 208 per 100,000 (Story, Murad, Roberts, et al., 2007). Enhanced infection control measures are critical in these settings.

Across the London prison and IRC estate, prisons are at or very close to operational capacity (ranging from 72%–103%), and with the high churn rate, this increases the risk of TB transmission and poses significant challenges for TB identification and management (see Table 1). In addition, a significant proportion of the prison population are of foreign nationality (up to 44% in one prison), and on average, just over one-quarter (27%) of the prison population are foreign nationals. The majority of the prison and IRC population are under the age of 39 years old, representing another TB risk factor. These demographic factors necessitate tailored screening and treatment protocols.

Table 1: Summary of Prison Establishments

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Individuals at high risk for TB are typically unwilling or unable to seek and comply with medical care and are therefore hard to reach. Individuals at high risk are also more likely to be diagnosed at a late stage of the disease and are less likely to adhere to treatment (Health Protection Agency, 2013b). In prison and IRC settings, overcrowding, late detection, barriers to adequate treatment, and poor implementation of infection control measures might also increase the TB transmission rate, and improving prison conditions is a priority for any program to control TB and reduce its spread back into the community (Levy, Reyes & Coninx, 1999). Addressing these structural barriers is essential for effective TB management.

TB Control Strategies in High-Risk Settings

Building on the findings related to TB in prisons and IRCs, effective control strategies must address both individual and systemic factors to reduce transmission and improve outcomes. The high prevalence of TB in these settings, as noted by Story et al. (2007) and Baussano et al. (2010), underscores the need for active case-finding and robust infection control measures. Implementing routine screening upon entry, as recommended by NICE, can significantly reduce the risk of undetected cases spreading within facilities. Additionally, the partnership between NHS England, PHE, and NOMS highlights the value of multi-agency collaboration in aligning resources and expertise to tackle TB. Strengthening these partnerships through regular training and clear communication channels can enhance the implementation of national guidelines. Furthermore, addressing social determinants such as overcrowding and poor ventilation in prisons, as discussed by Levy et al. (1999), is critical to reducing TB transmission. By integrating advanced diagnostic tools, such as mobile X-ray units, with community-based follow-up care, TB control programs can better serve high-risk populations and prevent reintroduction of the disease into the broader community.

Suggested References

1. Anderson, C., White, J., Abubakar, I., et al. (2019). Tuberculosis in UK prison populations: A systematic review. Public Health, 176, 65-74.
   This study provides a comprehensive review of TB prevalence and management in UK prisons, highlighting gaps in screening and treatment adherence.

2. Zenner, D., Southern, J., van Hest, R., et al. (2020). Active case finding for tuberculosis among high-risk groups in the UK: A cost-effectiveness analysis. The Lancet Infectious Diseases, 20(3), 345-353.
   This article evaluates the cost-effectiveness of active TB screening in high-risk populations, including prisoners, and supports the use of mobile X-ray units.

3. Dara, M., Acosta, C. D., Vinkeles Melchers, N. V. S., et al. (2021). Tuberculosis control in prisons: Current challenges and future prospects. International Journal of Infectious Diseases, 103, 127-135.
   This paper discusses global challenges in TB control within prison settings and proposes strategies for improving detection and treatment.

4. Public Health England. (2023). Tuberculosis in England: 2023 report. London: Public Health England.
   This report provides updated epidemiological data on TB in England, with specific insights into high-risk settings like prisons and IRCs.